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1 FastTest You ve read the book now test yourself To ensure you have learned the key points that will improve your patient care, read the authors questions below. Please refer back to relevant sections of the book to address any areas of uncertainty. Which of the following statements are correct? Note: there may be more than one correct answer per question.

2 1 Epidemiology and pathophysiology 1. In terms of the incidence of psoriasis: a) chronic plaque psoriasis is the most common form of the disease b) there is considerable interracial variation c) the peak age of onset is years d) men are more commonly affected than women 2. There are two types of chronic plaque psoriasis type I (common) and type II (uncommon). a) Type 1 tends to occur in young adults b) A positive family history is uncommon in patients with type I disease c) Type I disease tends to be mild and localized d) Type I disease tends to run an irregular course

3 3. The pathogenesis of psoriasis involves the interplay between environmental and genetic factors. a) Over 50% of patients with psoriasis have a known family history of the disease b) Nutritional deficiencies can be an important environmental trigger c) Excessive alcohol intake is associated with disease deterioration d) The major psoriasis genetic locus, PSORS1, contributes up to 50% of the genetic risk

4 2 Clinical presentation 4. Important clues to the diagnosis of psoriasis include a history of: a) atopic asthma and/or eczema b) persistent dandruff and/or scaling in the ears c) skin allergies d) joint problems e) autoimmune disease 5. Typically, chronic plaque psoriasis is: a) discoid in shape b) not itchy c) symmetrically distributed d) more common on thinner areas of skin

5 6. Comorbidities associated with psoriasis include: a) Crohn s disease b) lymphoma c) eczema d) metabolic syndrome e) cardiovascular disease

6 3 Differential diagnoses 7. A number of dermatological conditions may be confused with psoriasis. a) Mycological specimens should be taken from skin, hair or nails to differentiate Tinea infection (ringworm) from psoriasis b) The Koebner phenomenon is found in lichen planus but not in psoriasis c) A skin biopsy should be taken to differentiate psoriasis from hyperkeratotic forms of eczema on the hands and feet d) Contact dermatitis is seldom symmetrical and is more pruritic than psoriasis

7 8. Which of the following is/are psoriasis? (a) (b) (c) (d) (e) (f)

8 4 General management approach 9. Before starting treatment, useful advice for patients includes: a) Reassurance that early treatment can prevent the disease from becoming more severe b) Details of local side effects such as irritation or staining c) The benefits of active treatment, even for mild disease d) Information about stress reduction and management e) A warning that treatment is likely to be lengthy

9 10. Psoriasis is a chronic disease that requires long-term therapy. a) Relapse is likely if therapy is discontinued b) Longer-term remissions can be achieved with combined or rotational therapies than with any individual modality c) Combination therapy increases drug-related toxicity d) More toxic agents can be used to clear psoriasis followed by less toxic agents to maintain remission

10 5 Topical therapy 11. Choice of formulation will depend on patient preference and the site/pattern of psoriasis. a) Lotions tend to be most suitable for use at flexural sites b) Creams are less greasy than ointments and are therefore often prescribed for the face c) Ointments tend to be the preferred formulation for plaque psoriasis on the body d) Topical agents are particularly useful for the treatment of nail psoriasis

11 12. Corticosteroids are an integral component of topical therapy (first-line therapy in the UK and USA for chronic plaque psoriasis). a) Continuous use of corticosteroids may lead to loss of efficacy b) On stopping corticosteroid therapy, rebound psoriasis and a more inflammatory form of the disease may develop c) Side effects include irreversible skin bleaching d) Moderate or severe atopic eczema may complicate the use of topical corticosteroids e) Corticosteroids should be used alternately or in rotation with non-steroid-based therapies

12 13. The vitamin D 3 analogs calcipotriol, tacalcitol and calcitriol are all effective in chronic plaque psoriasis (first-line therapy in the UK and Europe). a) Efficacy is comparable to that of topical corticosteroids with mid-to-high potency b) Local side effects include tachyphylaxis and skin staining c) Onset of action is quicker than that of topical corticosteroids d) These agents can be used in combination with corticosteroids, phototherapy or systemic agents

13 6 Phototherapy and photochemotherapy 14. Phototherapy involves whole-body exposure to artificial sources of ultraviolet (UV) radiation a) Phototherapy involves the application of UVA radiation to the epidermis b) Phototherapy is usually given once weekly c) Topical corticosteroids used concurrently with phototherapy may increase relapse rates d) Phototherapy is well tolerated during pregnancy

14 15. Photochemotherapy (PUVA) involves the application of a photosensitizing drug (methoxsalen) in combination with UVA radiation. a) PUVA is contraindicated in patients with localized recalcitrant disease (e.g. palmar plantar psoriasis) b) Remission rates with PUVA are inferior to most other forms of therapy c) Methoxsalen remains in the eye for up to 12 hours after ingestion, necessitating appropriate eye protection after treatment d) PUVA is associated with a significant long-term risk of skin cancer

15 7 Systemic therapy 16. With systemic therapy, the benefits of disease clearance must be balanced against the risk of short- and long-term side effects. a) Most systemic therapies are associated with immunosuppression b) Systemic retinoids should be not be used in combination with PUVA c) Women should be advised to avoid conception for up to a year after acitretin therapy d) With ciclosporin therapy, the more inflammatory the psoriasis the more dramatic the response 17. Methotrexate is the gold standard of systemic therapy. a) Folic acid supplementation should be given concurrently with methotrexate b) Abrupt discontinuation of methotrexate may destabilize the psoriasis, which can lead to inflammatory flares c) Methotrexate is contraindicated during pregnancy or breastfeeding d) Methotrexate can be administered orally, intramuscularly or subcutaneously

16 8 Receptor-targeted (biological) therapies 18. Biological therapy targets specific molecules involved in the immunopathogenesis of psoriasis. a) At present, biological therapy is only licensed for patients with psoriatic joint disease b) Currently available biological agents are all administered by injection c) The biological agents used to treat psoriasis are associated with significant hepatotoxicity that warrants careful monitoring d) Biological therapies potentially reduce cardiovascular events in the psoriasis population

17 9 Psoriatic arthritis 19. Psoriatic arthritis is a common autoimmune inflammatory condition affecting the joints and entheses of patients with psoriasis. a) Onset of the disease is most common in people in their 20s and 30s b) Psoriatic arthritis, when it occurs, usually emerges before the appearance of skin lesions, which makes diagnosis difficult c) Women are more commonly affected than men d) Blood testing for rheumatoid factor is usually positive

18 20. In the treatment of psoriatic arthritis: a) long-term therapy with COX-2 inhibitors is a feasible option in patients with mild disease b) both methotrexate and ciclosporin have been shown to yield clinically significant improvements in joint disease c) biological therapies have been shown to inhibit the progression of structural damage d) biological therapies have been shown to significantly reduce fatigue, and improve function and quality of life

19 Thank you for taking this FastTest. There is no final score or certificate, but by reinforcing your understanding you have enhanced your clinical skills and practice. If you found the book useful, please spread the word about Fast Facts to your colleagues, students and patients.

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